Provider Demographics
NPI:1154319366
Name:DESCHENEAUX, CHARLES R (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:DESCHENEAUX
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2984 ALAFAYA TRL
Mailing Address - Street 2:#1030
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7628
Mailing Address - Country:US
Mailing Address - Phone:407-365-4040
Mailing Address - Fax:407-365-9800
Practice Address - Street 1:2984 ALAFAYA TRL
Practice Address - Street 2:#1030
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-7628
Practice Address - Country:US
Practice Address - Phone:407-365-4040
Practice Address - Fax:407-365-9800
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3108152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620387601Medicaid
FL620387600Medicaid
FLE1133Medicare ID - Type Unspecified
FLK3388Medicare ID - Type Unspecified
FLU71778Medicare UPIN